Mitigating The Psychological Impact of Terrorism: A Study on Cognitive Behavioral Therapy for Coping Strategies, Resilience and Psychological Distress Reduction

Abstract

Background: Terrorism exposure has severe psychological consequences, yet limited research has examined these effects among adolescents in conflict-affected regions of Pakistan or evaluated evidence-based interventions for this population.

Objective: This study examined the psychological effects of terrorism exposure among male adolescents (N=200, aged 16-18 years) in Khyber Pakhtunkhwa, Pakistan, comparing directly affected (n=100) and unaffected (n=100) individuals on depression, anxiety, stress, resilience, and coping strategies. The study further evaluated the efficacy of a 12-session Cognitive Behavioral Therapy (CBT) intervention among a subset of 30 highly distressed participants (experimental group n=15; waitlist control n=15).

Method: A quasi-experimental pre-test/post-test nonequivalent control group design was employed. Participants completed the Depression Anxiety Stress Scale-21 (DASS-21), Connor-Davidson Resilience Scale (CD-RISC-10), and Brief COPE Inventory. The experimental group received 12 weekly individual CBT sessions over three months.

Results: Directly affected participants demonstrated significantly higher psychological distress compared to unaffected participants: depression (M=22.36 vs. 4.50, t(198)=17.42, p<.001, Cohen's d=2.46 [95% CI: 2.09, 2.83]), anxiety (M=16.62 vs. 5.22, t(198)=12.72, p<.001, d=1.80 [95% CI: 1.47, 2.12]), and stress (M=25.08 vs. 7.76, t(198)=16.54, p<.001, d=2.33 [95% CI: 1.97, 2.68]). Affected individuals showed significantly lower resilience (M=11.83 vs. 32.42, t(198)=-37.45, p<.001, d=-5.29 [95% CI: -5.88, -4.70]) and reduced adaptive coping, with large between-group differences: problem-focused coping (M=12.11 vs. 16.42, t(198)=16.18, p<.001, d=-2.28), emotion-focused coping (M=25.87 vs. 29.44, t(198)=-12.81, p<.001, d=-1.81), and avoidance coping (M=26.84 vs. 14.10, t(198)=34.82, p<.001, d=4.92). Post-intervention, the CBT group showed significantly greater reductions than controls in depression (M=4.73 vs. 15.93, U=0.00, Z=-4.68, p<.001, r=0.86), anxiety (M=3.53 vs. 12.46, U=16.00, Z=-4.02, p<.001, r=0.73), and stress (M=5.40 vs. 20.13, U=0.00, Z=-4.67, p<.001, r=0.85). Within the experimental group, significant pre-to-post improvements emerged for resilience (M=10.60→33.53, Z=-3.41, p<.001, r=0.88), problem-focused coping (M=11.46→22.86, Z=-3.41, p<.001, r=0.88), emotion-focused coping (M=25.65→26.53, Z=-2.33, p=.019, r=0.60), and avoidance coping (M=25.85→12.80, Z=-3.41, p<.001, r=0.88). Clinically significant improvements were observed, with 86.7% of experimental participants moving from clinical to non-clinical ranges. All effect sizes ranged from large to very large (r=0.60-0.88; d=1.80-5.29), indicating strong clinical significance.

Conclusion: Terrorism exposure produces profound, clinically significant psychological distress in male adolescents, severely impairing resilience and adaptive coping. CBT demonstrates robust effectiveness in reducing distress and enhancing psychological resources in this population. These findings underscore the urgent need for accessible, trauma-informed mental health interventions in conflict-affected communities in Pakistan.